Argh….. Trigger is Not Cause. Don’t Let Them Get Away With It

When someone says, “My migraine is caused by stress (or the weather, or menses, or red wine),” they are wrong. They are trivializing and damaging people who have a serious disease. Don’t let them get away with it.

The important distinction between trigger and cause

There is a difference between a trigger and a cause. A trigger starts something that is primed to happen; while a cause is the reason for something to happen. A trigger is a small thing, and in the case of migraine ignores the things that are most important about why migraines happen. When a person does not make the distinction between trigger and cause they are harming themselves and other people with migraine.

Misplacing the blame

If I said my leg broke because I stepped on it too hard there might be a certain truthfulness to it. But, if I neglected to say there was a tumor with the consistency of Jell-O that had replaced 99% of the bone where it broke, I would be neglecting a much more important truth about my condition. When you let someone (maybe yourself) get away with thinking of migraine as caused by a trigger, it either makes it your fault (you ate that cheese after all) or hopeless (you are screwed; you can’t control the weather). It is like blaming a driver hitting a pothole on a road that has millions of them. It would be better to blame the road; then maybe it would get fixed.

Still helpful to try and manage triggers

I am not saying one shouldn’t manage stress, sleep better, and avoid certain food triggers. These are simply not causes. Migraine is a serious brain condition caused by things going wrong in the brain and pain nerves. The cause is complicated, argued about, and worth spending hundreds of millions of dollars to understand better. The cause of migraine includes genetic factors, brain remolding from exposures, and physical and other injuries that occur over a lifetime. In truth, it is hard to explain, and that is why it is difficult to get away from the oh-so-easy (but wrong) mind trick of flipping trigger and cause.

Prepare yourself with the right words

So let me suggest that the next time someone makes this mistake in your presence you say: “____ is just a trigger. You can’t live a real life and avoid all or even most triggers.” Be prepared for the question, “So what causes migraine?” My suggested answer is: “Migraine is a genetic and acquired predisposition of the brain’s pain, nausea, and light sensitivity centers to turn on together and incapacitate a person.” A nice flourish might be to add, “Do you realize it is the seventh most disabling medical condition? Mixing up trigger and cause belittles what is often a very serious disease.” Then turn it back to the perpetrator and ask them to use the word trigger if that is what they mean, not cause.

The words we use matter. They help to determine how migraine is framed in subtle and often quite negative ways. This little effort might do a great deal to change the way migraine is perceived. So please, take the pledge: “I will never let someone get away with mistaking trigger for cause.”

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Comments

Might also be worth mentioning that triggers don’t have to be immediate. A migraine can be triggered (not caused) by something to that occurred days before. They helps explain the middle of the night thing.

What bothers me about the article is the definition of migraine as a constellation of pain, light, nausea…many have migraine w o nausea. Vestibular migraine usually occurs w o pain, as do some hemiplegic episodes (my mother just went limp and experienced electrical pulsing). Some just have aura and no pain. These are all migraine events. No one knows where cluster fits but my neurologists both classify them as migraine and say it’s now common to do so. It’s odd, actually…I think many more people have migraine than realize. I have a craniosacral client w aura who insists she doesn’t get migraines, but who comes to me for relief from terrible headaches usually a day or two after the aura. She also can’t bear barometric changes or strong smells. But because the headaches don’t happen on the day of the aura, she isn’t interested in connecting them.

Good things to think about. People are always asking me what my cluster headache and migraine triggers are. For me, I feel like when they ask this they are really saying, “What did you do this time to get another migraine/cluster headache?”
Migraines are not something that I do to myself. Sure, I might slip up eat something that bothers me, or exercise too much, or whatever it might be, but this does not mean that they are my fault.
It is a lot that I have been given. Not something that I am doing myself.
For me, it is hard to deal with all the questions related to “triggers”. Even my doctor will say that I need to just work on eliminating my triggers and my migraines will leave.
Though I know in my heart that it is not something that I will be able to just eliminate my triggers. It is a disease that I have, and I will not be able to fix it by eliminating aged cheese, not eating gluten, or whatever it may be.
For now, I will just have to live through this and try to figure out the best solutions for me. I have had them since I was twelve and now 5 years later they are full blown chronic migraines that make me miss much of my still young life. I feel like migraines have aged me. Now I always have to worry about what I am eating, where I go, and the activities that I participate in. No one else my age understands this struggle. But for me, I have had to learn how to deal with chronic pain at such a young age.

Dr Young I’m a chronic migrainer and I do have triggers but not every time like when I get one in the middle of the night. What can you do to make people understand that this is a disease and not just, oh you just have a headache it will pass or you’ll be fine. If the medical community would let the government know that this truly is a disease maybe we would get the help that other diseases get.

Dear Patsy,
You are right, migraine is a disease and not a headache.
But I am sorry, you are wrong if you are asking what I (or doctors) can do to get better policies for persons with migraine. History shows only patients who come together can change the way a disease is perceived and the resources it gets.
I am the president of AHDA, the alliance for patient advocacy, bringing patients, doctors, and headache scientists to lobby for cures for migraine and justice from government policies toward patients with migraine and cluster headache. I have realized that unless patients stand up for themselves and educate and argue and fight for what is right, we don’t have a chance. That’s the only thing that can make things better.
So I turned my efforts to supporting Miles for Migraine and more recently the Coalition for Headache and Migraine Patients (CHAMP).
But nothing I have done and hope to do matters unless people like you stand up and are seen and heard. This might start by practicing talking to your family, friends and acquaintances about your disease. It might start by going to a walk for Migraine and bringing a family member or friend. It demands courage and creativity.
If you honor yourself by fighting for those with your disease, I promise others will honor you.
Sincerely,
Dr. Young

Frustrating article. Yes, trigger and causes are different but this article has terrible explanations on what a migraine is. If the medical community would change their approach and determine the cause of a persons migraines we could heal. Not all are genetics which is what this article seems to imply.

A less dichotomous way of looking at migraine is that it is like a free radical reaction:

Initiation
Propagation
Termination

It can be initiated at times by distinct triggers and at times by indistinct triggers
It can be propagated by brain vasoreactivity that involves reactive vasodilatation and vasoconstriction
It can be modulated by a lot of variables, such as light
It can be complicated by nausea, vomiting, severe pain
It can be terminated triptans among other agents

Initiation, propagation, modulation, complication, termination.

It is best not to dichotomize into “triggers” and “causes”.

It is best to integrate the whole process of having a migraine and there are more than two components of that continuum.

One can also think of it as being broken down into Onset, Progression, Recovery (or bounce back), Complication with the following factors being involved:

Onset
Risk factor(s) if present increase the probability of onset
Protective factor(s) if present decrease the probability of onset

Progression
Stress factor(s) if present increase the probability of progression
Resistance factor(s) if present decrease the probability of progression

Complication
Risk factor(s) if present increase the probability of complication
Protective factor(s) if present decrease the probability of complication.

So focusing on the issue of “trigger” versus “cause” diverts one from focusing on the complexity of migraine and on factors affecting onset and course of the disease.

Also “trigger” versus “cause” focus diverts one from looking at disease and interacting with the patient using a BioPsychoSocialCognitiveCulturalMotivational….etc Model of Interaction that plays off the “Power of Stories” to encourage self-awareness of what is happening before, during and after a migraine attack.

Thank you Dr Young! I have had years of people telling me that if I only did _ , I would be OK. As if I could control the universe! Although it has been sometimes intriguing to think of myself as a super-hero that can have that kind of control – that is just for my own musings. Your article really puts everything in its proper place with the appropriate hierarchy.

I plan to use your words to help define migraine disease when I get the same-old-same-old comments on what I should be doing for this really debilitating illness.

Ok good point, especially when one wakes up to a full blown migraine, am I supposed to stop sleeping? Triggers also in my experience are not always consistent which is why it’s hard trying to pin down what is causing them and leaves us with a painful condition that to this day has few concrete don’t do this or that options. Many are the times I’m fine one minute, to feeling the telltale signs beginning the next, yet having done nothing or been subjected to the triggers that I think brings it on and I’m not one who has the usual symptoms either, just the onset of pain that needs to be addressed asap before it gets to unbearable stage.

Dear Trena,
For some people triggers are very important and understanding what they are and controlling them can make all the difference. For others, not so much.
My point is about people taking this disease with the seriousness it requires.
Mistaking cause for trigger, I firmly believe, contributes to the misunderstanding and stigma attached to migraine. Imagine saying “my migraines are caused by red wine.” The public thinks “well just don’t drink it.” And they think this is not a serious disease.
We have to work together to de-stigmatize migraine.
Getting a little push back-ish when people say things like this will make a difference.
Best,
Dr. Young

THANK YOU Dr. Young! I’ve always felt that others place the responsibility on the migraineur, as though it’s our fault or within our control. My triggers have changed greatly over the years. Evan as a nurse I didn’t have much education about migraines. Practitioners are sorely lacking in education about migraines and pain! We need research and the medical community needs education. As I’ve learned and educated myself about migraine I’ve tried to educate others. It isn’t “just a headache!” We suffer brain attacks!

Trena Anderson,
We are glad that you enjoyed Dr. Young’s article. It is our responsibility as migraineurs to spread awareness about this debilitating disease so that migraine is perceived in a different light.
Thank you for pledging to educate others and shedding light on what we face during a “brain attack!”
Best,
Jillian (Migraine.com Team)

Wow! All I have ever been taught is about triggers. I like what you have to say, but can you follow up with answers? Most of us can only do the best we can to avoid these “triggers” because no one seems to have any answers for us. Reframing how we say something will not change it. I will get a migraine the next time the weather changes whether you call it a trigger or a cause. I need answers to help my “cause”!

Thank you for your feedback.
I understand your frustrations as weather change is one of my biggest “triggers.”

I think what Dr. Young is trying to get at, is that though we know that we can most likely expect a migraine with weather change, it is not the weather that is inherently causing the underlying issue.
Instead, we are dealing with a “serious brain condition” that involves many different factors. Dr. Young seems to be encouraging a sense of acceptance among migraineurs as opposed to blaming ourselves for things that are out of our control (such as weather).

Reframing how we talk about our disease can certainly help- the more light we shed on migraine and what it is truly like to live with, the more likely money will be allocated to migraine research. It is this very research that has enabled us to have hundreds of treatment options at our disposal.
Hopefully one day in the near future there will be a treatment specifically for weather induced migraine.

Very good article and reminder. Another thing that bothers me is the perception that Migraine equals headache. Headache is only part of the episode or attack. Migraine is a whole body experience. I suspect that some of the stigma that comes with migraine is the lack of clear understanding of migraine by the people experiencing it and the public. By understanding that includes the words used to describe or talk about it. I have been reading all the back pages on this site and notice that too many migrainers talk about their headaches. Wrong wording. We need more clear education about this so misunderstood condition.
This is a great statement and one I will carry with me.
“Migraine is a serious brain condition caused by things going wrong in the brain and pain nerves.” Thank you.

Luna,
Thank you so much for commenting on Dr. Young’s article and pledging to spread awareness about this chronic illness.
I love what you said about “migraine is a whole body experience.”
I can definitely attest to that.
I also thought you might be interested in reading this article which also addresses the difference between headache and migraine.https://migraine.com/blog/week-without/

Am amending the statement I will carry with me to either hand to people or read to them.
“Migraine is a serious brain condition caused by things going wrong in the brain and pain nerves.”
“Triggers are not cause. The cause of migraine includes genetic factors, brain remolding from exposures, and physical and other injuries that occur over a lifetime.”